The medium-term findings in coronary arteries by intravascular ultrasound in infants and children after heart transplantation

AbstractOBJECTIVESThe study purposes were to determine 1) whether intravascular ultrasound (IVUS) was more sensitive than angiography for the detection of post-transplant coronary artery disease (PTCAD) in pediatric patients; and 2) whether those transplanted as neonates reacted differently than older patients.BACKGROUNDExperience with IVUS for the diagnosis of PTCAD in children is limited.METHODSPatients were divided into two groups: those transplanted as neonates (early group) and those transplanted in infancy or childhood (late group). Morphometric analysis was performed, including maximal intimal thickness (MIT) and intimal index (II). Stanford classification was used to grade lesion severity. Acute rejection and cytomegalovirus (CMV) status were correlated with MIT and II.RESULTSThirty children were studied (early group, n = 13; late group, n = 17). All segments studied were angiographically normal. Mean MIT and mean II were significantly greater in the late group (0.26 ± 0.14 vs. 0.13 ± 0.04 mm, p < 0.001 and 0.11 ± 0.07 vs. 0.07 ± 0.03 mm, p = 0.04, respectively). There was a significant correlation between MIT and II in those who had acute rejection in the late group. Patients in the late group who were CMV-positive had a significantly higher MIT compared with those in the late group with negative serology (p = 0.04).CONCLUSIONSIntravascular ultrasound was more sensitive than angiography in detecting PTCAD after pediatric heart transplantation. There is a possible role for acute rejection and CMV in the development of PTCAD

The Future of Agriculture and Society in Iowa: Four Scenarios

Iowa is a leader in crop and livestock production, but its high productivity has had concomitant negative environmental and societal impacts and large requirements for fossil-fuel-derived inputs. Maintaining agricultural productivity, economic prosperity and environmental integrity will become ever more challenging as the global demand for agricultural products increases and the resources needed become increasingly limited. Here we present four scenarios for Iowa in 2100, based on combinations of differing goals for the economy and differing energy availability. In scenarios focused on high material throughput, environmental degradation and social unrest will increase. In scenarios with a focus on human and environmental welfare, environmental damage will be ameliorated and societal happiness will increase. Movement towards a society focused on human and environmental welfare will require changes in the goals of the economy, whereas no major changes will be needed to maintain focus on high throughput. When energy sources are readily available and inexpensive, the goals of the economy will be more easily met, whereas energy limitations will restrict the options available to agriculture and society. Our scenarios can be used as tools to inform people about choices that must be made to reach more desirable futures for Iowa and similar agricultural region

Early Predictors of Survival to and After Heart Transplantation in Children With Dilated Cardiomyopathy

Background— The importance of clinical presentation and pretransplantation course on outcome in children with dilated cardiomyopathy listed for heart transplantation is not well defined. Methods and Results— The impact of age, duration of illness, sex, race, ventricular geometry, and diagnosis of myocarditis on outcome in 261 children with dilated cardiomyopathy enrolled in the Pediatric Cardiomyopathy Registry and Pediatric Heart Transplant Study was studied. End points included listing as United Network for Organ Sharing status 1, death while waiting, and death after transplantation. The median age at the time of diagnosis was 3.4 years, and the mean time from diagnosis to listing was 0.62±1.3 years. Risk factors associated with death while waiting were ventilator use and older age at listing in patients not mechanically ventilated ( P =0.0006 and P =0.03, respectively). Shorter duration of illness ( P =0.04) was associated with listing as United Network for Organ Sharing status 1. Death after transplantation was associated with myocarditis at presentation ( P =0.009), nonwhite race ( P <0.0001), and a lower left ventricular end-diastolic dimension z score at presentation ( P =0.04). In the myocarditis group, 17% (4 of 23) died of acute rejection after transplantation. Conclusions— Mechanical ventilator use and older age at listing predicted death while waiting, whereas nonwhite race, smaller left ventricular dimension, and myocarditis were associated with death after transplantation. Although 97% of children with clinically or biopsy-diagnosed myocarditis at presentation survived to transplantation, they had significantly higher posttransplantation mortality compared with children without myocarditis, raising the possibility that preexisting viral infection or inflammation adversely affects graft survival

The impact of heart failure severity at time of listing for cardiac transplantation on survival in pediatric cardiomyopathy

The survival benefit of heart transplantation in adult heart failure is greatest for the sickest patients and negligible for patients not requiring inotropic or mechanical support. We hypothesized a similar survival benefit of heart transplantation for childhood cardiomyopathies with heart failure. A merged data set of children registered in both the Pediatric Cardiomyopathy Registry and the Pediatric Heart Transplant Study was used to assess differences in mortality before and after transplant in patients with different levels of heart failure severity. Severity was scored 2 if mechanical ventilatory or circulatory support was required, 1 if intravenous inotropes were required, or 0 if no support was required. For 332 eligible children, 12-month mortality after listing was 9% for those with a severity score of 0 ( n = 105), 16% with a score of 1 ( n = 118), and 26% with a score of 2 ( n = 109; p = 0.002) with a 3%, 8%, and 20% mortality with severity scores at listing of 0, 1, and 2, respectively, occurring before transplant. Patients listed with a score of 0 frequently deteriorated: 50% received an allograft or died before transplant with severity scores of 1 or 2. The risk of deterioration increased with previous surgery (relative risk, 3.84; p = 0.03) in the short-term and with lower left ventricular mass z-score at time of presentation (relative risk, 1.74; p = 0.003) in the longer-term. Pediatric cardiomyopathy patients who require high levels of support receive a survival benefit from heart transplantation that is not shared by patients not requiring intravenous inotropic or mechanical support

The impact of heart failure severity at time of listing for cardiac transplantation on survival in pediatric cardiomyopathy

BACKGROUND: The survival benefit of heart transplantation in adult heart failure is greatest for the sickest patients and negligible for patients not requiring inotropic or mechanical support. We hypothesized a similar survival benefit of heart transplantation for childhood cardiomyopathies with heart failure. METHODS: A merged dataset of children registered in both the Pediatric Cardiomyopathy Registry and the Pediatric Heart Transplant Study was used to assess differences in mortality before and after transplant in patients with different levels of heart failure severity. Severity was scored 2 if mechanical ventilatory or circulatory support was required, 1 if intravenous inotropes were required, or 0 if no support was required. RESULTS: For 332 eligible children, 12-month mortality after listing was 9% for those with a severity score of 0 (n=105), 16% with a score of 1 (n=118), and 26% with a score of 2 (n=109; P=0.002) with a 3%, 8%, and 20% mortality with severity scores at listing of 0, 1, and 2, respectively, occurring before transplant. Patients listed with a score of 0 frequently deteriorated: 50% were transplanted or died prior to transplant with severity scores of 1 or 2. The risk of deterioration increased with previous surgery (relative risk, 3.84; P=0.03) in the short-term and with lower left ventricular mass z-score at time of presentation (relative risk, 1.74; P=0.003) in the longer-term. CONCLUSION: Pediatric cardiomyopathy patients who require high levels of support receive a survival benefit from heart transplantation that is not shared by patients not requiring intravenous inotropic or mechanical support